“We Deserve Better!”: Perceptions of HIV Testing Campaigns Among Black and Latino MSM in New York City

Abstract

In 2014, Black/African-American and Hispanic/Latino men who have sex with men (BLMSM) comprised 64.1% of HIV diagnoses among MSM in the U.S. Routine HIV testing allows earlier diagnosis, linkage to care, and improved health outcomes. HIV testing campaigns may increase HIV awareness and testing behaviors, but perceptions of these campaigns by BLMSM have been understudied. We explored perceptions of HIV testing campaigns with BLMSM in New York City (NYC) to inform campaign strategies that target BLMSM for HIV testing. Using respondent-driven sampling methods, we conducted semi-structured interviews from 2011 to 2012 with BLMSM in NYC who participated in a larger HIV research study. Interview responses from 108 participants were examined for main themes using computer-assisted thematic analyses. The four main themes identified were that HIV testing campaigns should: (1) use non-stereotypical messages and images on the basis of race and sexuality, (2) use non-gay identified images, (3) be maximally inclusive and visible, and (4) raise risk perception of HIV. These findings can inform future campaigns for strengthening HIV testing among BLMSM in support of earlier diagnosis, linkage to care, and reduced disparities.

Introduction

In 2014, HIV diagnosis rates in the U.S., per 100,000 population, were 49.4 for Blacks/African-American, 18.4 for Hispanics/Latinos, and 6.1 for Whites (Centers for Disease Control and Prevention [CDC], 2015a). Similar racial/ethnic disparities were seen among gay, bisexual, and other men who have sex with men (MSM), as Black/African-American and Hispanic/Latino MSM (BLMSM) represented approximately 64% of new HIV diagnoses among MSM in the U.S. in 2014 (CDC, 2015b). BLMSM are at greater lifetime risk of acquiring HIV than White MSM; it is estimated that one in eleven White MSM, one in four Hispanic/Latino MSM, and one in two Black/African-American MSM will acquire HIV at some point in their lifetime (Hess, 2016). BLMSM comprised 68.8% of HIV diagnoses among MSM in New York City in 2012 (New York City Department of Health and Mental Hygiene, 2016). Reducing these HIV-related disparities is a key goal of the National HIV/AIDS Strategy (National HIV/AIDS Strategy [NHAS], 2015).

Individuals with undiagnosed HIV infection represent approximately 18.1% of people living with HIV in the U.S. and contributed to nearly a third of all HIV transmissions in 2009 (Skarbinski et al., 2015). HIV testing affords earlier diagnosis and subsequent treatment, which leads to improved health outcomes (Chopel, Minkler, Nuru-Jeter, & Dunbar, 2015; Cohen etal., 2011; Girardi, Sabin, & Monforte, 2007; Ransome et al., 2015). Expanded HIV testing coverage has also been linked to decreases in number of late HIV diagnoses (Ransome et al., 2015), which is particularly salient for Black/African-American and Hispanic/Latino populations, who often present later with new HIV diagnoses (Chopel et al., 2015). Later diagnosis leads to higher morbidity and mortality and reduces cost-effectiveness of antiretroviral therapy (Girardi et al., 2007). Earlier testing and diagnosis affords both individual and community benefits by allowing earlier treatment, which contributes to decreased morbidity and mortality and reduces onward transmission (Cohen et al., 2011; Grinsztejn et al., 2014).

One method of encouraging HIV testing is through the use of mass media campaigns. Mass media campaigns and interventions have been associated with changes in various health behaviors (Wakefield, Loken, & Hornik, 2010), including HIV testing (Castel et al., 2012; French, Bonell, Wellings, & Weatherburn, 2014; Martínez-Donate et al., 2010; Pedrana et al., 2012; Solorio et al., 2016; Vidanapathirana, Abramson, Forbes, & Fairley, 2005; Wei et al., 2011). Systematic reviews of HIV mass media campaigns have demonstrated that campaigns are effective in promoting positive sexual health behaviors (Noar, Palmgreen, Chabot, Dobransky, & Zimmerman, 2009; Vidanapathirana et al., 2005). HIV testing campaigns in New York City (NYC) have shown promise, with one study citing a 32% increase in past year HIV testing rates during the time of a popular HIV testing campaign (Myers et al., 2012). Therefore, research informing these campaigns could be beneficial by improving HIV testing rates. Perceptions of HIV testing campaigns among BLMSM have been understudied and may be useful in the development of future campaigns to increase HIV testing and reduce HIV-related disparities.

Method

Participants

Data were collected as part of a larger mixed methods study (Project BROTHA) (Nanin, 2013) which investigated HIV prevention communication among BLMSM in NYC, initially in partnership with a local community-based organization (Gay Men of African Descent). Due to the significant amount of racial and cultural overlaps among Blacks/African-American and Hispanic/Latinos in NYC, men who identified with either or both racial or ethnic backgrounds were recruited. Recruitment and data collection took place from March 2011 through August 2012 and included internet advertising (i.e., Facebook and social sites frequented by MSM) and distribution of promotional materials (i.e., pamphlets and flyers) in NYC communities. Both purposive and respondent-driven sampling methods (Heckathorn, 1997) were utilized for recruitment. Men were eligible to participate if they had not been tested for HIV within the previous three months, were 18–64 years of age, were able to communicate in English, were born male, self-identified as MSM, and were able to identify two other MSM from their social network. Following consent and enrollment, participants were asked to complete a computer-assisted survey (ACASI), consisting of questions concerning demographic, behavioral, and psychosocial data. After survey completion, participants took part in a semi-structured interview lasting approximately 45–75 min. Of the 112 participants enrolled, 108 completed both quantitative and qualitative portions of the study. Participants were reimbursed $60 for their time after completing the study. Project BROTHA was approved by Kingsborough Community College and Hunter College Institutional Review Boards and CDC (US Department of Health and Human Services, 2009).

In this article, we report qualitative analyses based on interview feedback about HIV testing campaigns. The main question was: “If you were to design a marketing campaign to try to encourage Black and Latino men who have sex with men to get tested for HIV, what would it look like?” along with several probes (Table 1). Most (>90%) of the interviews were conducted by a non-Hispanic White male who self-identified as Italian-American and MSM. Of note, at the time of data collection (2011–2012), at least two HIV awareness campaigns were very visible in NYC, including the NYC-developed: “When you get HIV, it’s never just HIV” (available at: http://www.nytimes.com/2011/01/04/nyregion/04hiv.html) and a CDC-developed campaign mentioned by at least one of our study participants: “Testing Makes Us Stronger” (available at: https://www.cdc.gov/actagainstaids/campaigns/tmus/).

Table 1.

Transcript question and probes used with Black and Latino MSM in NYC, Project BROTHA, 2011–2012

Question
If you were to design a marketing campaign to try to encourage Black and Latino men who have sex with men to get tested for HIV, what would it look like?
Probes
What kinds of messages would it send to these men?
Where would it be visible (i.e., online, in their neighborhoods)?
What kinds of imaging do you think would work best?
What form do you think this should take (i.e., posters, pamphlets) to be most effective?

Data Analysis

Qualitative analyses were conducted by two experienced researchers using applied thematic analysis (Guest, MacQueen, & Namey, 2011). Two qualitative analysts (KD and TA) read each interview and constructed a preliminary codebook from emergent themes. The codebook was then reviewed and finalized by two qualitative analysts; both analysts (KD and AM) independently coded each of the 108 interviews using NVivo 10 software (QSR International Pty. Ltd version 10, 2012). Next, analysts compared coding so that the inter-coder reliability was ≥0.80 for all codes (Hruschka et al., 2004). Any discrepancies in coding were settled through discussion and subsequent resolution.

Results

Participant Characteristics

Of the 112 BLMSM enrolled, four were excluded due to missing data; our final sample consisted of 108 BLMSM. Participants were mostly Black (86.1%), with 25.9% between 18 and 24 years old. Mean age was 34.9 years (range 18–64 years). Most participants self-identified as homosexual, gay, or queer (59.3%), followed by bisexual (33.3%), and “not sure/questioning” (6.5%). Participants were highly educated, with 67.5% having at least some college, associate’s degree, or technical degree. Forty-five percent reported being unemployed, and nearly 18% met criteria for poverty. Almost all (91.7%) participants had ever been tested for HIV, and 88.9% of participants reported their last HIV test as negative (Table 2).

Table 2.

Demographics and HIV testing history of Black and Latino MSM in NYC, Project BROTHA, 2011–2012 (n=108)

Demographics	N (%)
Age (years)
18–24	28 (25.9)
25–32	24 (22.2)
33–44	26 (24.1)
45–64	25 (23.2)
Missing	5 (4.6)
Race/Ethnicity
Black	93 (86.1)
Hispanic	14 (13.0)
Missing	1 (0.9)
Sexual orientation
Homosexual, gay, or queer	64 (59.3)
Bisexual	36 (33.3)
Not sure/questioning	7 (6.5)
Missing	1 (0.9)
Highest level of education completed
<Grade 12	13 (12.0)
Grade 12 or GED	21 (19.4)
Some college, associate’s degree, or technical degree	44 (40.7)
Bachelor’s degree	17 (15.7)
Any postgraduate studies	12 (11.1)
Missing	1 (0.9)
Current employment status
Employed full time	18 (16.7)
Employed part time	40 (37.0)
Unemployed	49 (45.4)
Missing	1 (0.9)
Poverty
Yes	19 (17.6)
No	89 (82.4)
Health insurance coverage
Yes	78 (72.2)
No	29 (26.9)
Missing	1 (0.9)
HIV testing history	N (%)
Ever tested for HIV
Yes	99 (91.7)
No	8 (7.4)
Missing	1 (0.9)
Result of most recent HIV test
Negative	96 (88.9)
Did not get results/indeterminate	3 (2.8)
Missing	9 (8.3)

Four major interconnecting themes arose from the analysis. Participants preferred HIV testing campaigns that (1) use non-stereotypical messages and images (based on race and sexuality), (2) use non-gay identified images, (3) are maximally inclusive and visible, and (4) raise risk perception of HIV.

Non-Stereotypical Messages and Images

Nine participants suggested that HIV testing campaign messages should refrain from using stereotypical images of BLMSM by sexuality or race. Some participants expressed dissatisfaction with stereotypical images used in certain locally and nationally developed campaigns seen in NYC during 2011–2012. One participant was dissatisfied with the way sexuality was portrayed, “…the [advertisements] I’ve seen they’re like very stereotypically gay, like you can tell that the, the people they use are gay. And so I’d probably just use very regular-looking men and women” (Hispanic/Latino, gay, 21). Another participant expressed strong opinions toward certain advertisements which he felt used stereotypical images:

…the advertising they have there (in the Atlantic City Tunnel) is completely pandering and semi-racist…to tell you the truth. Um, it’s like “we are stronger because we got tested” and it shows like, you know, this flaming queen who looks like, you know, she just fell off the back of a, of a bad pride float, bein’ like “wooo, hey girl”. Like…no. And then it’s like, you know, the typical “we are stronger” and it’s like, you know, a lesbian–obviously lesbian, uh, uh, Black lady with like you know–her hair’s in dreads and she has on no make-up but she has an under-lip piercing and she’s making a muscle. It’s like yea, can we be any more stereotypical? (Hispanic/Latino, gay, 33)

Several participants expressed concern with how gay men were portrayed. One participant indicated that some MSM may not want to be labeled as gay because they don’t want to be stereotyped. The following participant preferred images showing masculine men and working professionals to avoid stereotyping and display the diversity within the LGBT community:

I wouldn’t really put something that was flamboyant or a stereotypical gay male on there because everything is very stereotypical. I guess that’s why a lot of guys don’t want to admit to being gay because they don’t want to fall into that, they don’t want to be put into that stereotype. Because it’s like, you know, “Oh, my friend is coming, he’s gay.” You’re going to think that, or you’re more likely to think some guy in the tight pants with a shirt that’s tied up and looking like a female. I would put masculine men, professional, doctors, lawyers, pastors. (Black, gay, 24)

Portrayals of ethnicity and race were also a concern to participants. A few participants proposed using all types of media in a variety of locations and neighborhoods so that one race or community would not feel particularly “singled-out.” One participant mentioned how campaigns can sometimes leave someone feeling racially stereo-typed by using targeting tactics (i.e., promoting HIV testing and only distributing Magnum^™ condoms): “I wouldn’t like to go, like, stereotypical…they were advertising…you could feel the target—they said, um, ‘…HIV testing, and they’ll supply you with Magnums^™ at the end’ ” (Black, gay, 25). Another participant had issues in the way HIV testing campaigns were sometimes targeted specifically to men of color: “I’d say that’s like profilin’, sayin’ that only Black people and Spanish people get the disease” (Black, gay, 27).

Campaigns Focused on Non-gay Identified Men

Twelve participants indicated that they would prefer campaigns that were for non-gay identified men; they desired some campaigns that did not focus on effeminate men. Participants preferred campaigns which “take the sexuality out of the equation” (Black, other, 40) or were not “so over-the-top flamboyant” (Black, gay, 24). Many participants offered reasons for not including “gay-looking” men in HIV testing campaigns. One participant suggested using images of men which do not appear as homosexual because MSM may not wish to identify as gay due to possible connotations associated with the word “gay”:

And you know (some) guys who have sex with men do not want to be called gay…because…if I consider myself gay then I’m losing, that means I’m losing my masculinity. Because gay, the word gay is associated with somebody that is flamboyant. In our time, generation, it’s being associated with flamboyant drag queen, feminine, non-masculine. That word is non-masculine to many. (Black, gay, 24)

Similarly, other participants indicated that campaigns should be non-gay identified because members of the Black/African-American and Hispanic/Latino communities may not wish to identify themselves as gay or lesbian:

Just, um, not as, not as aggressively, uh, identified as gay, lesbian, and whatever. Because so many people in the-, uh, communities of color don’t associate themselves with being a lesbian or gay, you know. They may do some of those actions, but they don’t associate themselves with those groups. (Hispanic/Latino, gay, 33)

Others described how the idea of homosexuality may not translate well in communities of color. One participant described that campaign messages should not allude to any sort of gay identity because some men of color may not want to identify themselves as homosexual even though they may practice homosexual behaviors:

…I feel like the identity of being gay or bi or queer or something else, kind of, doesn’t necessarily translate well onto Black and Latino communities, like men who have sex with men because some of the…MSM don’t necessarily see themselves as part of that community. They just see themselves as like, this is an action that I do, or like a, you know, something, fleeting. And that doesn’t’ necessarily mean that like I’m a gay, or bi, or queer man that identifies as that. So, I guess…I wouldn’t use that phrasing. (Hispanic/Latino, gay, 25)

Many participants stated that when public health officials draw upon more stereotypically gay signifiers of gender (i.e., perceived as feminine), this may inadvertently exclude a portion of the target audience as some MSM may not necessarily identify with the LGBT community. One participant preferred non-gay identified campaigns in an effort to reach a wide variety of Black/African-American and Hispanic/Latino men, not differentiating by sexuality:

You’d wanna target Black and Latino men who don’t feel comfortable getting tested because maybe there’s a stigma attached to it, like maybe they think it’s a gay thing and they don’t, um, identify with homosexuality or don’t identify themselves as being homosexual…So yea, not associating having sex with men necessarily being gay because they might think being gay is, you know, kids hanging out in the village…You just need to try to get all Black and Latino men, not really distinguishing… (Hispanic/Latino, gay, 29)

One participant recounted his personal experience with discovering and identifying with his own sexual identity. He suggested that it may have been easier for him as well as other MSM to identify with campaign messages if they were non-gay identified. To address this, another participant suggested using more masculine imagery:

…it would have to be a image where it wouldn’t really portray them as bein’ like, homosexual, for them to really, you know what I’m sayin, pay attention to it…It would have to be a little bit more on the hardcore base, and more on a, on a manly basis…They have these feelings, you have these feelings and…You don’t want the world to perceive those, you know, what your situation is, you know. You don’t, you don’t mind being involved in it, but you don’t want it to be known. (Black, bisexual, 52)

Although many men expressed an interest in using campaign messages that they perceived to be focused on non-gay identified men, four participants recommended that campaigns use portrayals of BLMSM that display gay couples in a positive light and five participants believed campaigns that showed a diverse array of men by sexuality and masculinity would be effective. One participant indicated he was pleased with a campaign running during the time of the study which stressed the importance of getting tested in homosexual relationships: “I feel that’s important because it’s showing like a positive image of a homosexual relationship between two men of color” (Black and Hispanic/Latino, gay, 24). Another participant spoke highly of a recent campaign that displayed diversity within the BLMSM community saying, “I think it was excellent because it was diverse, it had men who were very aggressive looking, and men who was passive, it had transgenders” (Black, gay, 31).

Maximizing Visibility and Inclusiveness in Campaigns

Seventeen participants stressed the importance of making campaign messages visible and culturally inclusive for BLMSM. Participants indicated that campaigns may be more effective if members of the audience were able to “see themselves” (Black, gay, 26) and if the images in the campaigns were to “reflect the people of [their] community” (Hispanic/Latino, gay, 39). One participant indicated that if people are able to “see somebody that look like them…they can more or less relate to them” (Black, gay, 44).

Some proposed using influential people from within their community such as famous rappers and hip-hop artists to serve as advocates. Another participant revealed that increasing visibility may encourage members of their community to get tested:

It has to be something that Black men can relate to…I don’t think, you know, a picture of, you know, two men riding a bike in the park, you know, holding hands in the picture…is really going to attract us…now if you had two sexy brothers on the same picture…then that can kind of relate to us, ok, they look like they are from our way, they look like they are right out from our neighborhood, ok, you know, that kind of makes it a little bit more easier, ok, you know like, well, if they can represent that, then I can, you know go get tested. (Black, gay, 32)

Many proposed using language and terminology that was inclusive and wide reaching to their communities, including using different languages, age-appropriate lingo, and easily comprehensible terminology. A couple of participants stressed the importance of having bilingual messages in English and Spanish in order to reach the Hispanic/Latino population. Participants also expressed a desire for visible and inclusive images, as one participant illustrated:

And I feel like it’s really important to, to showcase a familiar Spanish image, you know. Cuz I feel like, when you look at most pamphlets and everything, it’s only focused, targeted towards Black gay men…So, it’s really important for them to have a familiar image so they can also see that it’s not only Black guys…if you could give somebody a clear symbol of their culture, then the message could resonate within them further. (Black, gay, 20)

While participants desired targeted images according to race and ethnicity, many believed using a universal approach in terms of sexuality would be more visible to BLMSM. In an effort to make messages inclusive and visible to many, one participant suggested a more general approach to HIV testing campaigns:

Um, having more mainstream visuals to go along with that, uh, may have more people feeling included. Um, because when I see, you know, the obvious you know straight up dyke, you know, there, I think to myself “Who is gonna relate to that except other straight up bull dykes?”, you know? And that is a small subsection. (Hispanic/Latino, gay, 33)

The same participant later explained feeling disenfranchised and further suggested using more visible and inclusive images:

We deserve better…this African-American lady in a business suit…who happens to be a lesbian…she, she deserves better, she deserves better than what she’s getting. And I feel like that, because I feel disenfranchised. I deserve better…And I may not look necessarily like that women, there in her little business suit, but you know, she is a woman of color, she does sleep with other women. So, she’ll associate herself with that… (Hispanic/Latino, gay, 33)

Campaigns to Raise Risk Perception

Twenty-one participants suggested using campaign messages that attempt to raise HIV risk perception. Some participants desired to stress the importance of personal susceptibility of acquiring HIV by showing rates of HIV within different communities, using personal testimonies, demonstrating that anyone can be susceptible to HIV, or highlighting that HIV doesn’t have a “look.” One participant believed it is important to demonstrate that anyone can get HIV, “…HIV really doesn’t like, discriminate against anyone, like you’re not immune to it” (Black, gay, 24). Similarly, another participant thought that an effective campaign slogan might be “It only takes one time” (Black, gay, 26), demonstrating that it is possible to obtain HIV with even one risky act. Some warned against the use of “sickly-looking” images as it may mislead the audience regarding the appearance of persons living with HIV infection. Instead, some suggested using people who appeared healthy to suggest that “you don’t have to look sick…or feel sick for you to be an HIV carrier” (Hispanic/Latino, gay, 54). Similarly, others suggested using a range of images to emphasize that anyone, including yourself, could have HIV and could be at risk. One participant suggested:

If you put a picture of five different people on there, and you say, “Who has HIV?” Or you. You could, you put it like…anyone of these people can look like you. That’s it. You can just leave it simple like that. Let them know that their next door neighbor, or the school teacher, to the police officer, to anybody, or you, or anybody you just meet for the first time…Put a normal face on it, and let people know, hey this could be me too… (Hispanic/Latino, bisexual, 44)

Several participants believed that it would be effective to use diverse images to communicate risk and susceptibility. One participant suggested using imagery of people from diverse backgrounds of age, race, and physical attractiveness in order to convey risk:

…you see flashes of different types of guys, all different kinds, you know, like handsome ones, young ones, old ones, Black, Hispanic, whatever, saying how, you know, “I’m at risk”. You know, and then the last person you know, say “We all at risk” and so on. I think it would be really effective. (Black, gay, 44)

Another participant believed it would be important to emphasize that physical appearance is not a good measure of HIV status and anyone can potentially have HIV:

I would get um, the people that work out, you know what I’m sayin’. They body all buffed up, big and strong and then tellin’ people like…”and I’m HIV-positive”…cuz looks are deceiving…It could happen to anybody…don’t look at me and think you can tell what my status is. I think I would do it like that. (Black, bisexual, 51)

Others felt it would be particularly important to raise risk perception in groups that may have lower perceived risk such as youth, incarcerated populations, and MSM who do not identify as homosexual. One participant noted:

I think you’d really wanna reach out to them (MSM who don’t identify as homosexual) because I think they’re the ones that would be most at risk…saying you don’t identify with being gay but you’re still at risk if you have sex with other men. (Hispanic/Latino, gay, 29)

Discussion

Our analysis explored perceptions of HIV testing campaigns by BLMSM in NYC. Findings indicated that our participants preferred campaigns that were: (1) non-stereotypical by sexuality and race, (2) non-gay identified, (3) maximally inclusive and visible, and (4) able to raise risk perception of HIV. The four themes interconnected in some ways. Themes one and two demonstrate the participants’ desire for campaigns to reflect what they felt to be non-gay identified perspectives, as some men suggested that MSM in communities of color may not wish to identify themselves as homosexual, despite practicing same-sex behaviors; this is often due to homophobia and stigma which are prevalent in many communities of color (Malebranche, 2008). This feeds into how some BLMSM negotiate their own sexual identities, which in turn may cause them to see themselves in a risk group that is not necessarily congruent with practiced risk behaviors. Some participants suggested campaigns should raise risk perception for HIV acquisition and transmission.

Participants felt that campaign images that are non-stereotypical in terms of race and sexuality would be most effective in reaching BLMSM. Although not intentionally, HIV campaign messages can sometimes perpetuate stereotypes (DeJong, Wolf, & Austin, 2001) and lead to harmful effects such as stigmatization (Cho & Salmon, 2007; Guttman & Salmon, 2004). Previous HIV campaign efforts occasionally left our participants feeling stereotyped, erased, and invisible on the basis of race and sexuality. Stereotypical images of homosexual men used in campaigns, as well as subtle cues such as location of campaign materials in “at risk” neighborhoods, caused participants to feel stigmatized. Unintended effects of campaign messages, such as those mentioned by our study participants, have been understudied (Friedman, Kachur, Noar, & McFarlane, 2016) and could be counterproductive to efforts to increase HIV testing.

To engage BLMSM while avoiding stereotyping, participants suggested that campaigns be what they viewed as focused on “non-gay identified” men. While urging for campaigns which did not show men as “gay,” the participants were really demonstrating their desire not to be stereotyped as effeminate merely because they have sex with men. Traditional masculinity roles among men in the U.S. may be endorsed more among Black/African-American and Hispanic/Latino men than men of European descent (Levant & Richmond, 2008). Furthermore, Black men may associate gay sexual identity with femininity (Kisler & Williams, 2012; Malebranche, Fields, Bryant, & Harper, 2007). Thus, campaigns for “gay” men may require broader imagery to resonate well with a wider range of BLMSM. This strong desire to uphold masculine characteristics by some men of color may result from a history of racism, oppression, and poverty, which may increase the complexities of developing appropriate and diverse messages for MSM of color. This could in turn lead to poorer health outcomes, especially as it concerns sexual health (Kisler & Williams, 2012). In the context of a legacy of oppression, masculinity becomes a precious resource which must be fiercely defended by men of color (Lemelle & Battle, 2004). Interestingly, many of our participants who preferred campaigns that were non-gay identified actually identified as gay themselves. This could be a reflection on what participants felt men in their community would be more responsive to but also hints at forms of internalized homophobia, which is reflected in some of the more heterosexist and masculinist narratives.

Some research has been conducted regarding campaigns which deemphasized homosexual identity in order to reach heterosexually identified Hispanic/Latino MSM populations; these have been an effective means of reaching this audience (Fernández Cerdeño et al., 2012;Martínez-Donate et al., 2009; Solorio et al., 2016). Campaigns which do not emphasize homosexual identity, or what some BLM SM believe to be homosexual (i.e., femme), may be a means of reaching a portion of BLMSM which, the participants felt, is not often reached in campaigns; further research in this area is warranted.

It is similarly important to recognize the diversity of participant responses with respect to homosexually identified campaigns. While many expressed an interest in campaigns which were what they perceived to be as non-gay identified, some participants expressly stated they would enjoy seeing images that represented men of all sexualities and masculinities. Campaigns which exhibit diversity regarding sexuality and masculinity may be an effective means of reaching a wider BLMSM audience.

Although participants believed campaign messages should not be targeted on the basis of sexual preference, they indicated that familiar cultural and racial images should be used in campaigns. BLMSM felt that visible and inclusive images would be most effective in reaching this population. These findings are corroborated by a study among MSM in the UK which demonstrated that using inclusive images by ethnicity were correlated with increases in HIV testing among the targeted subgroups (McOwan, Gilleece, Chislett, & Mandalia, 2002). Other studies have similarly shown that ethnically relevant images and messages may be effective in reaching communities of color (Olshefsky, Zive, Scolari, & Zuñiga, 2007; Wallace, McLellan-Lemal, Harris, Townsend, & Miller, 2011; Wang & Arpan, 2008). Reaching specific communities while also not being stigmatizing requires very informed and sometimes nuanced approaches that are best developed in conjunction with the target audiences.

To encourage BLMSM to get tested for HIV, participants suggested using campaign messages that raise risk perception of HIV. Studies of HIV media campaigns that included elements to raise risk perception suggest mixed findings in several British-based samples; U.S. media campaigns have been understudied in this area (French et al., 2014). A study conducted with Hispanic/Latino MSM revealed that one barrier for HIV testing was low levels of perceived risk (Solorio, Forehand, & Simoni, 2013). Men felt their risk for HIV was low, because they or their partner had a healthy physical appearance or believed their behaviors did not place them in a high risk group (i.e., primarily had sex with women and occasionally had sex with men, only practiced oral or insertive anal sex with men) (Solorio et al., 2013). These findings, along with ours, underscore that, in addition to increasing HIV risk awareness within this population, it is also important to strengthen messages about HIV testing as a part of routine medical care, with increased testing frequencies based on new sex partners, condomless sex acts, or other risky sex behaviors (Chou et al., 2012). Furthermore, a well-aligned perception of HIV risk is especially important in this current era of pre-exposure prophylaxis (PrEP) for HIV-negative persons who are increased risk of HIV exposure. For HIV-negative MSM who are aware of potential HIV risk, discussions with healthcare providers about PrEP availability and use can provide opportunities for PrEP as an additional HIV prevention tool (CDC & US Public Health Service, 2014). Our findings suggest that HIV prevention campaigns, including those that are Pr EP-focused, may warrant considering messages that are non-stereotypical and maximally inclusive while also raising risk perception of HIV.

Importantly, 33.3% of our participants self-identified at bisexual. Some studies suggest that bisexual BLMSM may be even less likely to disclose due to HIV-related stigma and internalized and community-level homophobia (Malebranche et al., 2007). Therefore, non-stereotypical and non-gay identified HIV testing campaigns may be particularly important for this subgroup of BLMSM. Given the heterogeneity among BLMSM, it is important that campaign developers account for audience segmentation for resonance with the intended audience (Plant et al., 2010) and to avoid making assumptions such as a “one-size-fits-all” attitude, which may result in campaign images and messages that inadvertently marginalize BLMSM (Spieldenner & Castro, 2010). More research is needed regarding how to best develop HIV testing campaigns for bisexually active BLMSM.

Strengths and Limitations

Our study has several strengths, yet is not without limitations. Regarding strengths, using qualitative analysis allows exploration of nuances of human behavior that cannot be easily found with quantitative analyses (Morgan & Smircich, 1980). Thus, we were able to hear from the men directly regarding their thoughts about HIV testing campaigns. Second, we analyzed 108 semi-structured interviews, a strong sample size in qualitative studies, which allowed for greater confidence in the quality and representativeness of the main themes.

Regarding limitations, first, the generalizability of our results is limited due to the use of purposive sampling methods in a single urban location (NYC). Further research is needed to investigate perceptions of HIV testing campaigns among other BLMSM in other parts of the U.S. Second, because our study included participants from ages 18–64 years, results are not generalizable to BLMSM outside of this age range. As young BLMSM are increasingly affected by new HIV diagnoses (CDC, 2015b), including this group in future studies is vital to developing age-appropriate HIV prevention messages. Third, because the semi-structured interviews were one-on-one and not matched with a BLMSM interviewer, social desirability bias and lack of cultural relatability may have affected some participants and made them less prone to give honest answers. Fourth, our study did not include any preliminary work to assess specific images included in the campaigns seen by participants; additional research is needed on the effectiveness and reach of using diverse imagery by race and sexuality in the evaluation of campaigns which target BLMSM. Lastly, the use of a $60 incentive could have also influenced the types of participants enrolled in our study; however, this amount of incentive was minimal compared with other federally funded HIV prevention research studies in NYC at the time and was not an amount that was felt to be coercive.

Conclusions

These data add to the scarce body of the literature regarding perceptions of HIV testing campaigns by BLMSM and may help the efforts of public health professionals who develop health communication campaigns. Our findings offer unique insight into ways that BLMSM may be better reached in HIV testing campaigns (i.e., portraying men who are not stereotypical and who feel familiar to men in Black and Latino communities). While it is important to note the views of these participants, and it may be a means of reaching out to an audience that has felt invisible, it is equally important to note that BLMSM possess a wide range of views about masculinity and homosexuality. It is of equal importance to reach out to men who identify as femme as well as macho. Campaigns which are not limited to a single subset and are able to reflect the diversity within the BLMSM community are warranted to maximally expand the reach of HIV prevention efforts. Given potential reach and cost-effectiveness of mass media campaigns (Wakefield et al., 2010), these findings can inform future HIV testing campaigns for BLM SM in support of earlier HIV diagnosis, linkage to care, and reduced disparities, consistent with the goals of the National HIV/AIDS Strategy (NHAS, 2015).